Oral ulcers and mucosal disease — branching viva

Opening — the drooling febrile toddler

Examiner: A two-year-old boy has three days of high fever, drooling and refusal to drink, with a diffusely swollen, bleeding gingiva and shallow vesicles and ulcers across the gingiva, tongue and lips. Talk me through your immediate thoughts and your examination. [1]

Candidate should cover: the diagnosis of primary herpetic gingivostomatitis from the fever, drooling and diffuse anterior gingival vesicles and ulcers; the recognition that dehydration from refusal to drink is the practical threat; and a focused assessment of hydration (moist mucous membranes, capillary refill, urine output) alongside the oral and systemic examination. [1]

Branch 1 — hydration-first management and early aciclovir

Examiner: How will you manage him, and what is the role of aciclovir? [2]

Candidate should cover: analgesia with paracetamol and ibuprofen, a soft cool diet and cool fluids, and correction of any fluid deficit with nasogastric or intravenous fluid where the child cannot maintain oral hydration; and early oral aciclovir 15 mg per kilogram per dose (maximum 200 mg per dose) five times daily for five to seven days started within 72 hours of onset, with intravenous aciclovir for severe disease, immunocompromise or a child who cannot maintain hydration. [1] [2]

Branch 2 — the school-age child with recurrent scarring aphthae

Examiner: Now a different child: a ten-year-old with recurrent ulcers larger than ten millimetres that last weeks and heal with scarring. What has changed, and what will you do? [9]

Candidate should cover: the classification as major aphthous stomatitis on non-keratinised mucosa, distinct from herpetic gingivitis; the deficiency and systemic work-up of a full blood count with differential, iron studies, serum folate and vitamin B12, coeliac serology with total IgA and C-reactive protein; the stepwise topical management with a topical corticosteroid, chlorhexidine mouthwash and a topical analgesic; and the systemic differential of Behcet disease, inflammatory bowel disease and cyclic neutropenia if genital, eye or systemic signs appear. [9] [10]

Branch 3 — the infant with thrush

Examiner: Finally, a two-month-old breastfed infant with white wipeable plaques on the buccal mucosa, and the mother has sore pink shiny nipples. What is the diagnosis and the management? [8]

Candidate should cover: the diagnosis of oral candidiasis from the white wipeable plaques in an infant; topical nystatin oral suspension 100,000 units per millilitre, 1 mL to each side of the mouth four times daily after feeds for seven days; the treatment of maternal nipple candidiasis to prevent reinfection; the caution with miconazole oral gel in young infants who cannot control the gel at the gum; and a low threshold to investigate if the thrush is unexpected or refractory, since immunodeficiency may present this way. [8]